Database Capture Form – Fill Out and Use This PDF

Ownership Structure

1.

Name &

Country of

Surname

Origin

Identity No

Please, mark the appropriate box with a X

Female

Male

Living with a Disability

Briefly describe disability

Position in

Organisation

%Ownership

Qualifications

Other courses

attended

Relevant

Experience

2.

Name &

Country of

Surname

Origin

Identity No

Please, mark the appropriate box with a X

Female

Male

Living with a Disability

Briefly describe disability

Position in

Organisation

%Ownership

Qualifications

Other courses

attended

Relevant

Experience

3.

Name &

Country of

Surname

Origin

Identity No

Please, mark the appropriate box with a X

Female

Male

Living with a Disability

Briefly describe disability

Position in

Organisation

%Ownership

Qualifications

Other courses

attended

Relevant

Experience

4.

Name &

Country of

Surname

Origin

Identity No

Please, mark the appropriate box with a X

Female

Male

Living with a Disability

Briefly describe disability

Position in

Organisation

%Ownership

Qualifications

Other courses

attended

Relevant

Experience

Total number of Employed staff

Number of Permanent Staff					Number of Temporary staff
Previous Contract or Tendering Experience
Employer/Dept		Tender No			Year Awarded		Value (Rand)

CONTRACTOR REGISTRATION CHECKLIST

Prior to submitting your Enterprise Database Application Form, please ensure that the following documents are attached.

	DOCUMENTS ATTACHED	Yes	No	N/A
1	Proof of Ownership

(a)Identity Document(certified not older than three months)

(b)Company /close corporation documents(certified)

(c)CIDB Grading (if registered)

(d)Original Tax Clearance

(e)Declaration of ownership, Management ,control (affidavit)

(f)Any other proof.(Letter Head, crossed cheque, financial statements, etc.)

2	Proof of Address ( a minimum of three (3 ) documents )

(a)Bank statements

(b)Letter from local leadership

(c)SARS document stating address

(d)Municipal utility account

(e)Any other account (six months and older)

3	Proof of disability (for disabled contractors)

(a)Letter from the district Medical Practitioner

(b)Additional Information(X-Ray, Accident Reports, etc.)

4	Proof of work done (Grade 2 and 3 ) new applicants

(a)Letter of award

(b)Completion letter or certificate

(c)Payment Certificates

5	OPTIONAL DOCUMENTS

(a)Company Profiles

(b)Any other documents

N.B. Grade 4, 5 and 6 contractors, who wish to register for the first time, are not allowed to register on the Vukuzakhe Emerging Contractors Database.

DECLARATION BY EMERGING CONTRACTOR UNDER OATH

I/We …………………………………………………………………………………………declare that I / we are

fulltime active members of this business entity with regard to the management, ownership and control, and that the above particulars and information furnished to the Department of Transport for the purposes of registering our organization on the Vukuzakhe Emerging Contractor database are true in substance and in fact and that I/We fully understand the meaning thereof. I / We further agree to abide with the rules and principles of the Vukuzakhe Emerging Contractor Programme of the Department of Transport KZN.

Name: ……………………………………………………………. Signature: ……………………………

Date: …………………………………… Designation: ……………………………………………….

ID Number…………………………………………….

Name: ……………………………………………………………. Signature: ……………………………

Date: …………………………………… Designation: ……………………………………………….

ID Number…………………………………………….

Name: ……………………………………………………………. Signature: ……………………………

Date: …………………………………… Designation: ……………………………………………….

ID Number…………………………………………….

Name: ……………………………………………………………. Signature: ……………………………

Date: …………………………………… Designation: ……………………………………………….

ID Number…………………………………………….

Name: ……………………………………………………………. Signature: ……………………………

Date: …………………………………… Designation: ……………………………………………….

ID Number…………………………………………….

Signed and sworn before me at …………………………………………………………… on this the

……………day of ……………………………….by the Deponent, who has acknowledged that he/she

knows and understands the contents of this affidavit, that it is true and correct to the best of his/her knowledge and that he/she has no objection to taking the prescribed oath, and that the prescribed oath will be binding on his/her conscience.

…………………………………………………………………………………

COMMISSIONER OF OATHS

Name& Surname:…………………………………………….Signature………………………………….

SAPS NO:…………………………………………… RANK………………………………………………..

STAMP

NOTE: EMERGING CONTRACTORS PROVIDING FALSE OR FRAUDULANT INFORMATION OR NOT DISCLOSING RELEVANT INFORMATION PERTAINING TO THIS APPLICATION OR SUPPORTING DOCUMENTATION SHALL SUBJECT THEMSELVES TO IMMEDIATE DISQUALIFICATION.

FURTHERMORE THE DEPARTMENT RESERVES A RIGHT TO INTERVIEW ALL THE OWNERS OF THIS BUSINESS ENTITY TO VERIFY INFORMATION PROVIDED IN THIS DOCUMENT.

NOTE: INCOMPLETE SUBMISSIONS WILL NOT BE PROCESSED. THIS INCLUDES THE SUPPORTING DOCUMENTATION AS STIPULATED ON THE ABOVE PAGES.

For Office Use Only

_____________________________	____________________________
Recommended/ Not Recommended	Date
Senior Admin Clerk
_________________________	____________________________
Supported/Not Supported	Date
Admin Officer
____________________________	____________________________
Approved/Not Approved	Date
Signature of Ass Manager Database
	Interview

___________________________________	____________________________
Official Signature	Date